Oral bisphosphonate use is associated with increased incidence of upper gastrointestinal (GI) adverse effects (eg, oesophagitis, gastritis) compared with placebo.1-2,11 Evidence for an association between bisphosphonate use and risk of oesophageal cancer is conflicting.3,9,12-13

To minimise the risk of upper GI adverse effects, advise patients to take oral bisphosphonates in the morning prior to fooda and to remain upright for at least 30 minutes afterwards.1

Due to safety concerns, the TGA issued a safety alert for strontium ranelate in 2014, restricting its use to patients unable to use other medicines for osteoporosis.20 In August 2016, strontium ranelate was delisted from the PBS.

Osteonecrosis of the jaw (ONJ) is a rare complication of intravenous bisphosphonates, seen mostly in patients with bone metastatic malignancies.21-22 The risk of ONJ with oral bisphosphonates or denosumab tends to be much lower with the doses used for osteoporosis.3,9,23 Advise patients to maintain good dental hygiene and to stop bisphosphonate treatment if ONJ is confirmed.1-2

Stop bisphosphonate therapy if
an atypical femoral fracture occurs

The absolute risk of atypical femoral fracture (AFF) with long-term use of bisphosphonates or denosumab is very low.24 The overall benefit in preventing hip fractures with bisphosphonates greatly outweighs the risk of AFF.3 Consider AFF if the patient develops pain in the thigh, hip or groin.9 If AFF is confirmed, stop bisphosphonate therapy and check for contralateral AFF.9

Monitor treatment response and review therapy to encourage adherence

Approximately 40% of people taking osteoporosis medicines do not meet levels of adherence needed to obtain full benefit from their treatment.25

Use BMD measurements to monitor treatment response

Therapeutic response can be monitored by measuring BMD at the lumbar spine and hip.1 Obtain BMD measurements 2 yearsb after commencing therapy or 1–2 years after therapy changes significantly.1

Guidelines recommend measuring BMD prior to starting long-term corticosteroids and at least once a year for the first few years of therapy, in patients taking prednisolone (≥ 5 mg/day) or equivalent.c,1

Review diagnosis and treatment regimen if BMD losses greater than 3%–5% per year are observed in a patient taking osteoporosis medicines.2

Evaluate medicine effectiveness and adherence, or investigate for underlying causes of osteoporosis if:

Date published: 13 November 2017Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition. NPS MedicineWise disclaims all liability (including for negligence) for any loss, damage or injury resulting from reliance on or use of this information. Read our full disclaimer. This website uses cookies. Read our privacy policy.